Chapter 66 Flashcards
First line agents for AF rate control
Beta blocker
CCB: verapamil, diltiazem
Beta blockers for SND + tachy-brady syndrome (2)
Pindolol
Acebutolol
intrinsic sympathomimetic activity- provide rate control without aggravating sinus bradycardia
True of digitalis:
A. Works mainly by decreasing vagal tone
B. Recommended as alternative for rate control
C. Increases risk of all-cause mortality in AF
D. Works adequately in exertional tachycardia
C
Digitalis:
does not provide adequate rate control during exertion
works mainly by increasing vagal tone
no longer recommended for rate control except in patients with heart failure
increase the risk of all-cause mortality
Guidelines recommend digoxin for rate control only in patients with heart failure
ADD: from MS chapter
Ivabradine - decreases HR during exercise, but do not decrease LA-LV gradient
BB- decreases LA-LV gradient, no effect on exercise
Name the Trial:
Class IIb recommendation for catheter ablation of AF in asymptomatic patients
CABANA trial
No difference in the primary end-point
Secondary end-point of death or cardiovascular hospitalization was significantly lower in the ablation arm than the medical arm
CASTLE AF STUDY- Primary composite endpoint of death from any cause or hospitalization for worsening heart failure was lower in the ablation arm
True of Amiodarone:
A. First line agent in rhythm control of AF
B. Belongs to Class III anti-arrhythmic drug
C. First line anti-arrhythmic in HF patients only
D. All of the above
B
Risk of organ toxicity associated with long-term therapy:
Amiodarone can be an appropriate choice for rate control if the other agents are not tolerated or are ineffective
An appropriate choice for a patient with persistent AF, heart failure, and reactive airway disease who cannot tolerate either a CCB or a BB and who has a rapid ventricular rate despite treatment with digitalis
class IIb recommendation in the 2014 ACC/AHA/HRS AF Guidelines
Classof anti-arrhythmics with QT-prolonging side effects resulting to Torsades de Pointes:
A. Class II
B. Class Ia
C. Class III
D. B and C
D
Class Ia agents (quinidine, procainamide, disopyramide)
(sotalol,
Class III agents (dofetilide, dronedarone, amiodarone)
Risk factors for developing prolonged QT among patients on AAD (4)
Female
LV dysfunction
Hypokalemia
Concomitant use of QT-prolonging drug
AF is associated with the following by how many times?
1. Cerebrovascular accident (stroke)
2. All-cause mortality
3. Cognitive dysfunction
4. Stroke in post-op AF
5
2
2
2
Name the trial:
sustained weight loss and exercise decreases AF burden
LEGACY
The only percutaneous occlusion device approved by
the FDA specifically for stroke prevention as an
alternative to warfarin
WATCHMAN device
nitinol plug covered with fenestrated fabric
After implantation, anticoagulation with warfarin is recommended for at least 45 days
DOACs can be used instead of warfarin
Device approved by FDA for soft tissue approximation (not stroke prevention)
LARIAT
Percutaneous or surgical LAA occlusion are class IIa and IIb recommendations in situations where anticoagulation is contraindicated.
AAD used to lowers the defibrillation energy requirement & improves the success rate of transthoracic cardioversion
Ibutilide
ORAL agents for acute conversion of AF
Propafenone (300 to 600 mg)
Flecainide (100 to 200 mg).
Flecainide-surveillance on first use due to pronounced post conversion pause
-“pill-in-the-pocket” approach
Both have increase propensity for ventricular fibrillation in the setting of myocardial ischemia or infarction- NOT RECOMMENDED IN CAD
Risk of torsades de pointes appears to be much lower
with these Class III AAD
dronedarone and amiodarone
minimally invasive procedure used to treat resistant hypertension that is associated with a significant reduction in both BP and AF burden at 12 months’ follow-up
Renal denervation
Cause of AF in diabetes (2)
Probably because of fibrotic changes in the atria and downregulation of connexin-43
Cause of AF with alcohol intake (2)
Direct cellular effects on atrial myocytes with acute
oxidative stress, and also from activation of the
sympathetic nervous system
abstinence from alcohol results in a
reduction in AF burden
BMI target for AF reduction among obese
Goal of weight loss ideally should be a BMI of
≤27 kg/m2
Role of ablation in AF
Palliative measure
AF ablation should NOT be
considered a “cure” for AF but rather a palliative measure to keep the patient in sinus rhythm for as long as possible
Optimal ablation technique for eliminating
triggers and drivers of AF
electrical isolation of PV
Name the trial: outcomes of AF ablation were similar in the cryoballoon and RF arms of the study.
CIRCA-DoSE TRIAL
AF burden reduced by approximately 98%.
What is a strong
independent predictor of durable PV isolation?
Disappearance or dissociation of PV potentials within the first minute of a cryoenergy application is a strong
independent predictor of durable PV isolation.
other predictors:
oTemperature recorded by a thermocouple proximal to the balloon of at least −40°C within 60 seconds of an application of cryoenergy
oan interval thaw time to 0°C of >10 seconds upon completion of a cryoenergy application.
What is the most feared complication of AF ablation?
atrial-esophageal fistula
oChest CT with intravenous contrast is the diagnostic test of choice.
- contrast in the esophagusor air in the mediastinum or cardiac chambers is indicative of an esophageal perforation or fistula formation.
How to reduce risk of causing atrial-esophageal fistula during ablation?
Limiting the power of RF energy applications to 20 to
25 watts for < 30 seconds when ablating along the posterior left atrial wall
